Receiving care from an out-of-network provider can result in bills that dwarf what you expected to pay. Balance billing — where the provider charges you the difference between their fee and what your insurer pays — has been a major source of surprise medical bills. The No Surprises Act, effective January 2022, provides significant but not total protection.
What is a Out-of-Network Coverage?
Out-of-network coverage refers to how your health insurance handles claims from providers who are not in your plan's contracted network. Plans with out-of-network benefits (PPOs, POS plans) cover some portion of out-of-network costs at a higher cost share. Plans without out-of-network benefits (most HMOs, EPOs) cover nothing for out-of-network care except in emergencies. Balance billing is when a provider bills you for the difference between their charge and what your insurer pays — this is now prohibited in many emergency and surprise billing scenarios under the No Surprises Act.
Red flags to watch for
If you see an out-of-network provider (other than in a true emergency), you may owe 100% of the cost. Make sure your specialists and preferred providers are all in-network before enrolling.
Many plans have separate deductibles and out-of-pocket maximums for out-of-network care. Out-of-network costs may not count toward your in-network protection, leaving you with unlimited exposure.
Your plan's reimbursement for out-of-network care is typically based on an allowed amount — which can be far lower than the provider's actual charge. You may owe the full difference beyond what is prohibited.
If your plan lacks sufficient in-network specialists, you may be forced to go out-of-network. Plans should have a network adequacy standard and a process to designate out-of-network care at in-network rates when no in-network option exists.
The No Surprises Act protects you from balance billing by out-of-network providers in emergency situations and for certain ancillary care at in-network facilities.
Your legal rights
Under the No Surprises Act (effective January 1, 2022), you are protected from surprise bills for: emergency services at any facility; non-emergency care from out-of-network providers at in-network facilities (unless you consent in advance); and air ambulance services from non-participating providers. Your cost share cannot exceed the in-network rate in these situations.
Questions to ask before you sign
- 1Does this plan have out-of-network benefits, and what is the cost-share percentage?
- 2Is there a separate out-of-network deductible and out-of-pocket maximum?
- 3Do out-of-network costs count toward my in-network out-of-pocket maximum?
- 4How is the allowed amount for out-of-network care calculated?
- 5What process exists to get out-of-network care covered at in-network rates when no in-network provider is available?
Disclaimer: This guide is for educational purposes only and does not constitute legal advice. Contract law varies by jurisdiction and individual circumstances. Always consult a qualified legal professional before making decisions based on this information.